Latest Review Date: July 2024

Category: Administrative

POLICY

NOTE: Coverage may be subject to legislative mandates, including but not limited to the following, which apply prior to the policy statements:

• Federal Women’s Health and Cancer Rights Act (WHCRA)
• Minnesota Statute 62A.25 Reconstructive Surgery

A service is considered cosmetic when performed primarily to enhance or otherwise alter physical appearance without an expectation of correcting or improving physiological function, except when performed for any of the following:

• To correct a condition resulting from an accident, trauma, or medical emergency; or
• To correct a congenital birth defect; or
• To correct a functional impairment which results from a disease or injury; or
• Incidental to, or following, surgery resulting from an injury, sickness or other diseases of the involved body part.

NOTE: This policy does not apply to the following:

• Services addressed by a specific medical policy utilized by Blue Cross and Blue Shield of Minnesota (Blue Cross).
• Gender-affirming procedures that are addressed by Blue Cross medical policy 685.

DESCRIPTION OF PROCEDURE OR SERVICE

This policy describes criteria by which Blue Cross determines whether a service is considered Cosmetic in the absence of a specific medical policy. Cosmetic services are not considered eligible for coverage.

Definition: A service includes, but may not be limited to, a treatment, procedure, surgery, and associated supplies.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

KEY POINTS

Blue Cross Blue Shield medical directors are asked by providers to make determinations of cosmetic status for various treatments and procedures.  It is not possible to have medical policies in place for all potential requests. In the absence of a specific Blue Cross policy, medical directors will use this policy to make determinations that are consistent with State statutes, BCBSMN member contract language, and local practice.

Summary of Evidence

Blue Cross Blue Shield medical directors are asked by providers to make determinations of cosmetic status for various treatments and procedures. In the absence of a specific Blue Cross policy, those requests will be reviewed according to this policy to ensure appropriate eligibility for coverage.

Federal and State Mandates

Various federal and state statutes and administrative rules address the definition of cosmetic as a permissible exclusion by health plans. Relevant statutes and administrative rules are noted below:

MN STATUTES: CHAPTER 62E.06 MINIMUM BENEFITS OF QUALIFIED PLAN

Sub1.C(2)

c) Covered expenses for the services and articles specified in this subdivision do not include the following:

(2) any charge for treatment for cosmetic purposes other than for reconstructive surgery when such service is incidental to or follows surgery resulting from injury, sickness, or other diseases of the involved part or when such service is performed on a covered dependent child because of congenital disease or anomaly which has resulted in a functional defect as determined by the attending physician;

MN ADMINISTRATIVE RULES: CHAPTER 4685, HEALTH MAINTENANCE ORGANIZATIONS

4685.0100 DEFINITIONS.

Subp. 5a. Cosmetic services. "Cosmetic services" means surgery and other services performed primarily to enhance or otherwise alter an enrollee's physical appearance without correcting or improving a physiological function.

MN ADMINISTRATIVE RULES CHAPTER 4685, HEALTH MAINTENANCE ORGANIZATIONS

4685.0700 COMPREHENSIVE HEALTH MAINTENANCE SERVICES.

Subp. 4. Permissible exclusions. The following services may be excluded:

1. personal convenience devices;
2. cosmetic services, except for reconstructive surgery as required under Minnesota Statutes, section 62A.25;

Minnesota statute differentiates the cosmetic exclusion from reconstructive surgery, which must be covered as noted in the regulations below:

MN STATUTES: CHAPTER 62A.25, RECONSTRUCTIVE SURGERY

Subd. 2. Required coverage. (a) Every policy, plan, certificate or contract to which this section applies shall provide benefits for Previous reconstructive surgery when such service is incidental to or follows surgery resulting from injury, sickness or other diseases of the involved part or when such service is performed on a covered dependent child because of congenital disease or anomaly which has resulted in a functional defect as determined by the attending physician.

(b) The coverage limitations on Previous reconstructive surgery in paragraph (a) do not apply to Previous reconstructive breast surgery following mastectomies. In these cases, coverage for Previous reconstructive surgery must be provided if the mastectomy is medically necessary as determined by the attending physician.

(c) Previous Reconstructive surgery benefits include all stages of reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prosthesis and physical complications at all stages of a mastectomy, including lymphedemas, in a manner determined in consultation with the attending physician and patient. Coverage may be subject to annual deductible, co-payment, and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the plan or coverage.

Women’s Health and Cancer Rights Act of 1998 (PL105-277)

The Women’s Health and Cancer Rights Act (WHCRA) provides protections for individuals who elect breast reconstruction after a mastectomy. Under WHCRA, group health plans offering mastectomy coverage must also provide coverage for certain services relating to the mastectomy, in a manner determined in consultation with the attending physician and the patient. Required coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses, and treatment of physical complications of the mastectomy, including lymphedema.

Blue Cross and Blue Shield of Minnesota Contracts

The Minnesota Department of Commerce (DOC) regulates the language used by health plan contracts in Minnesota. The DOC recently approved the following definition of “cosmetic” which is currently included in commercial member contracts:

[Exclusion Section]: Operations for cosmetic purposes done to improve the appearance of any portion of the body, and from which no improvement in physiological function can be expected, except as otherwise provided herein. Other exceptions to this exclusion are: a) surgery to correct a condition resulting from an accident; b) surgery to correct a congenital birth defect; c) surgery to correct a functional impairment which results from a covered disease or injury; and, d) Services incidental to or following surgery resulting from injury, sickness or other diseases of the involved body part.

Government Programs

The Medicare Benefit Policy Manual defines cosmetic surgery and associated coverage below:

Cosmetic surgery or expenses incurred in connection with such surgery is not covered. Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member. For example, this exclusion does not apply to surgery in connection with treatment of severe burns or repair of the face following a serious automobile accident, or to surgery for therapeutic purposes which coincidentally also serves some cosmetic purpose.

Similarly, Minnesota Health Care Plans (MHCP) excludes coverage for

• Surgery mostly for cosmetic reasons;
• Drugs used mainly for cosmetic reasons.

Practice Guidelines and Position Statements

American Society of Plastic Surgeons

The American Society of Plastic Surgeons defines cosmetic procedures on their website as:

Cosmetic plastic surgery includes surgical and nonsurgical procedures that enhance and reshape structures of the body to improve appearance and confidence. Healthy individuals with a positive outlook and realistic expectations are appropriate candidates for cosmetic procedures. Plastic surgery is a personal choice and should be done for yourself, not to meet someone else’s expectations or to try to fit an ideal image. Because it is elective, cosmetic surgery is usually not covered by health insurance.

Community Practices

Locally, other Minnesota health plans have medical policies which similarly define “cosmetic.” HealthPartners posts a policy on their website titled “Cosmetic Surgery/Treatments” which provides a definition of cosmetic which is generally consistent with BCBSMN. PreferredOne defines “cosmetic” in their posted “Cosmetic Treatments” medical policy.

BENEFIT APPLICATION

Coverage is subject to member’s specific benefits. Group-specific policy will supersede this policy when applicable.

ITS: Covered if covered by the Participating Home Plan

FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan.

REFERENCES

1. 1. American Society of Plastic Surgeons. Cosmetic Procedures. www.plasticsurgery.org/cosmetic-procedures.
2. Centers for Medicare & Medicaid Services. The Center for Consumer Information & Insurance Oversight. Women’s Health and Cancer Rights Act (WHCRA). www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/whcra_factsheet.html.
3. HealthPartners. Medical policy: Cosmetic Services/Treatments. August 2018. www.healthpartners.com/public/coverage-criteria/policy.html?contentid=AENTRY_046277.
4. Medicare. Medicare Benefit Policy Manual. Chapter 16, sub 120 Cosmetic Surgery. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c16.pdf.
5. Minnesota Statute Administrative rules. Health Maintenance Organizations. 4685.0100 Definitions. Subp. 5a.
6. Minnesota Statute Administrative rules. Health Maintenance Organizations. 4685.0700 Comprehensive Health Maintenance Services. Subp. 4.
7. Minnesota Statutes. Chapter 62A.25 Reconstructive Surgery. Subp. 2.
8. Minnesota Statutes. Chapter 62E.06 Minimum Benefits of Qualified Plan. Subp1.C(2).
9. Minnesota Health Care Plans Provider Manual. MHCP Member Evidence of Coverage. www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=DHS16_179701#ncs
10. PreferredOne. Medical policy: Cosmetic Treatments. March 2018..preferredone.com/shared/medicalpolicy/MedicalPolicyActive/mp_c002.pdf.

POLICY HISTORY

Reviewed and posted July 1, 2021

April 2022: Annual review completed. No change to policy intent.

May 2023: Annual review completed. No change to policy intent.

May 2024: Annual review completed. Policy Statement updated- added “or medical emergency.” Updated Description and added Key Points and References sections.

July 2024: Off-cycle review. No change to policy intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1.  The technology must have final approval from the appropriate government regulatory bodies;
2.  The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3.  The technology must improve the net health outcome;
4.  The technology must be as beneficial as any established alternatives;
5.  The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1.  In accordance with generally accepted standards of medical practice; and
2.  Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3.  Not primarily for the convenience of the patient, physician or other health care provider; and
4.  Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.